21382 Floating Cabin Electrical Certification Form

TVA RESTRICTED INFORMATION
OMB No. 3316-0060
Exp. Date xx/xx/xxxx

Tennessee Valley Authority
Floating Cabin Electrical Certification Form
Owner #1 Mailing Information (Required)

Owner #2 Mailing Information

Name

Name

Street

Street

City ____________________ State___________ Zip code

City ____________________ State___________ Zip code

Email Address

Email Address

Home Phone

Home Phone

Mobile Phone

Reservoir:______________________

Mobile Phone

FC-UID:_______________ TVA Permit ID:

Electrical System Compliance Certification
In accordance with 18 CFR 1304.103(e), floating cabin owners shall provide certification of compliance with the electrical standards of 18 CFR
1304.103(e)(1) and (2) with their initial permit application and by October 1 of every even-numbered year thereafter. The certification must be signed
by a licensed electrical engineer, a state-certified electrical inspector, or a person certified by the International Association of Electrical Inspectors, the
International Code Council, or an equivalent organization.
Signature (Required)
I certify that I have inspected this floating cabin and it complies with 18 CFR 1304.103(e)(1) and (2) as of the date inspected.

Date Inspected

Inspector Name (Printed)

Inspector Signature

License Number (or applicable information)
18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of The United States knowingly and willfully falsifies,
conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false
writing or document knowing same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five
years, or both.

Privacy Act Statement
This information is being requested in accordance with Section 26a of the TVA Act. Disclosure of the information requested is voluntary; however, failure to provide any
required information or documents may result in a delay in processing your application, in your being denied a Section 26a permit, or in your Section 26a permit being
revoked. An application that is not complete will be returned for additional information. TVA uses this information to assess the impact of the proposed project on TVA
programs and the environment and to determine if the project can be approved. Information in the application is made a matter of public record through issuance of a
public notice if warranted. Routine uses of this information include providing to federal, state, or local agencies, and to consultants, contractors, etc., for use in program
evaluations, studies, or other matters involving support services to the program; to respond to a congressional inquiry concerning the application or Section 26a program;
and for oversight or similar purposes, corrective action, litigation or law enforcement.
The information requested in this form becomes part of the Section 26a Permit Application Records Privacy Act System of Records (TVA-36). Authority for maintenance of this system
of records is provided by the Tennessee Valley Authority Act of 1933, 16 U.S.C. 831-831ee. The information solicited on this form may be made available as a "routine use." A
complete list of the routine uses can be found in the system of records notice associated with this form, "Section 26a Permit Application Records, TVA-36." TVA's system of records
notices can be found on the TVA website at https://www.tva.com/information/about-the-tva-privacy-program.

Burden Estimate Statement
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to Agency Clearance Officer, Tennessee Valley Authority, 1101 Market
Street, Chattanooga, Tennessee 37402; and to the Office of Management and Budget, Paperwork Reduction Project (3316-0060), Washington, D.C. 20503.

TVA 21382 [xx-xx-2022]

Page 1 of 1
TVA RESTRICTED INFORMATION